ALS Drug Guide - Paramedic Tutor

ADVANCED LIFE SUPPORT Drug Guide for Paramedics

Copyright 2012

Author Rob Theriault BHSc., EMCA, RCT(Adv.), CCP(F)

Copyright 2012, 2009, 2008, 2007, 2004, 2003, 2002, 2001, 1996 Reproduction of any part of this material, written, audio, visual or electronic, in any form, without the written consent of author is strictly forbidden.

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Table of Content

The following guide provides a description of drugs for Primary and Advanced Care Paramedics in the field.

Page "Seven Rights" of drug administration.............................................. 3 Adenosine ......................................................................................... 4 Amiodarone ...................................................................................... 6 Aspirin ............................................................................................... 8 Atropine ............................................................................................ 10 D50W ................................................................................................. 12 Diazepam.......................................................................................... 14 Dimenhydrinate................................................................................. 16 Diphenhydramine.............................................................................. 18 Dopamine ......................................................................................... 20 Epinephrine IV, SC ........................................................................... 22 Fentanyl ............................................................................................ 24 Furosemide ....................................................................................... 26 Glucagon .......................................................................................... 28 Lidocaine .......................................................................................... 30 Midazolam ........................................................................................ 32 Morphine ........................................................................................... 34 Naloxone........................................................................................... 36 Nitroglycerin ...................................................................................... 38 Oxygen ............................................................................................. 40 Salbutamol (Ventolin) ...................................................................... 42 Sodium Bicarbonate ......................................................................... 44 Xylometazoline HCL (Otrivin)............................................................ 46

Medicine and pharmacology is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The author and publisher of this document have has used his best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the author and publisher does not warrant that the information in this document is accurate or complete, nor is the author responsible for omissions or errors in the document or for the results of using this information. The reader should confirm the information in this document from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed. In addition, the drug indications and dosages described in this guide are based on general guidelines and principles of drug administration and do not replace or supersede your Medical Directives or Standing Orders.

For additional continuing medical education resources visit Paramedic Tutor at:

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Seven "Rights" of Drug Administration

1. Right Patient? Is this patient right for this drug? Is this drug contraindicated because of medical history, allergies, drug interaction, presenting condition, heart rate, blood pressure, mental status, etc?

2. Right Drug? some drugs come is similar ampoules, vials or nebules (e.g. epinephrine and morphine, naloxone and midazolam ) ? always check the drug when you pull it out of the kit for the name, dose, concentration and for fluid clarity and expiry date. Check the drug again before administering it. syringes with left over medication must be labelled with the drug name and concentration per ml. A narcotic should be checked by two people prior to administration (except when alone in the back of the ambulance)

3. Right Dose? double check dosage calculation - have partner do the same when practical Is your estimation of the patient's weight reasonable? The Broselow? tape is recommended for weight estimation in paediatrics

4. Right Time? Follow dosing intervals listed in Medical Directives. Remember that repeated doses of a drug may have an added effect. Timing may be critical to maintain a therapeutic drug level

5. Right Route? Which route is most appropriate for this patient ? e.g. SC, IM or IV. In the case of anaphylaxis for example, SC may be acceptable in the early stages, however, once shock has set in, the IM route is better.

6. Right to know? patient has a right to be informed about the drug; What the drug is and what it does; benefits and risks; a right to sound medical advice

7. Right to refuse You must obtain permission from the patient for any intervention The patient has the right to refuse treatment at any time e.g. it's not uncommon for patients to refuse ASA for various reasons e.g. some patients will refuse Adenosine because it causes them great physical distress or they know it hasn't worked for them in the past. Assess patient's "capacity" in the event of a refusal and use the Base Hosp. Physician and/or supervisor for assistance

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Adenosine (Adenocard)

Classification:

antiarrhythmic

Pharmacodynamics: naturally occurring nucleoside that stimulates specific adenosine receptors. This results in activation of acetylcholine sensitive potassium channels (efflux of potassium) and blockade of calcium influx in the SA node, atrium and AV node. The cells become hyperpolarized and this blunts SA node discharge, slows AV conduction and increases the AV node refractory period. AV nodal conduction may be completely blocked.

interrupts AV nodal re-entry and other AV node dependant tachyarrhythmias

Pharmacokinetics: Intravenous

ONSET PEAK HALF-LIFE DURATION

20-30 seconds unknown 6-10 seconds 1-2 minutes

Indications:

conversion of supraventricular tachycardia (SVT) / paroxysmal supraventricular tachycardia (PSVT) including that associated with Wolff-Parkinson-White syndrome

Contraindications:

hypersensitivity, 2nd or 3rd degree AV block, sick sinus syndrome

Precautions:

may worsen bronchospasm in asthmatics and some patients with COPD

flushing and chest pain may occur briefly after administration.

drug to drug:

higher than normal doses of Adenosine may be required for patients on xanthines (eg. theophylline).

lower than normal doses (i.e. 3 mg or less) should be used for patients on dipyridamole (Persantine) as this drug potentiates Adenosine.

the effects of Adenosine are prolonged in patients taking Carbamazepine (anti-convulsant) and in heart transplant recipients (denervated hearts)

Adverse effects

crushing chest pain, flushing, SOB, N/V, lightheadedness, dizziness, syncope, etc

explain to the patient they will likely experience some of the above symptoms

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Dosage:

Pediatric SPECIAL NOTES:

6 mg IV bolus (FAST!) -followed by an immediate 20-30 cc of NS or R/L flush - run ECG strip as drug is being given

12 mg IV bolus (FAST!) -followed by an immediate 20-30 cc of NS or R/L flush - may be repeated in 1-2 minutes if the first dose is ineffective.

Note: Adenosine must be given very quickly and in the IV site closest to the central circulation (e.g. antecubital, external jugular, central line). It should always be immediately followed by a 20-30 cc flush of NS or R/L to make sure that all of the drug is cleared from the IV tubing and delivered to the intended site

0.1 - 0.2 mg/kg rapid push (flush with 2-20 cc IV fluid depending weight of child)

has a > 90% successful conversion of PSVT rate when the full dose is given (Crankin et al, 1989; Garrat et al, 1989; DiMarco et al, 1990)

has an extremely short half life of 10 seconds or less ? consequently, as many as 40% of patients may revert back into PSVT

Once the drug is given, the patient may be experience a period of asystole of 3-15 seconds. A variety of other rhythms may also appear on the ECG ( e.g. second or thirddegree heart block). Because of the drug's short half life, these effects are generally self-limiting

Sometimes rapid Atrial Fibrillation is difficult to distinguish from a regular SVT. If that occurs turn the volume up on the cardiac monitor. This will provide an auditory clue that the rhythm is irregularly irregular. Map out the R-R interval to see if the rhythm is regular (SVT) or irregular (A. Fib.). Use the patient's history and medications as a guide ? i.e. the elderly patient on digoxin and coumadin is more likely to be in an atrial fib. The younger patient is more likely to be in an SVT.

Transport of the patient should not be delayed as other treatments/drugs may be required in hospital should SVT/PSVT recur

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